I’m going to be honest here: I still get confused about some aspects of insurance.

I have worked with insurance companies in various settings over the last 5 years as a practitioner, and in the past as a patient. The various types of plans, benefits, and costs can make you dizzy even if you are working within the industry, so how can you have any chance of understanding the nuances? I’m going to give some basic information that will help the average consumer make an informed decision.

First, there are two major types of plans, HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) with quite different models of reimbursement. The major differences are as follows: HMOs require a referral for any services to be covered, typically from your PCP (primary care physician), a PPO does not. You also will not have an Out of Network (OON) benefit from an HMO, whereas most PPOs do have OON benefits.

Sometimes, you can receive reimbursement from your insurance company for services provided by an OON provider, if you've met your deductible. 

A provider can be either In Network, or Out of Network with third party payers, which ultimately means they either accept the reimbursement rates for their services, or they don’t. The current state of In Network care in the Physical Therapy world is one of declining reimbursements for the same care while costs to provide that care (rent, equipment, salaries, etc.) rise. This leads to clinics being forced to focus on volume instead of outcomes to keep the lights on.

Some insurance plans reimburse better than others, or have different caps on therapy as well, further compounding issues with scheduling. At many clinics, your insurance will determine how long your appointment is, who it is or isn’t shared with, and what interventions can take place. This is simply unacceptable and unethical, as the patient’s needs should come first. Below are some definitions of common pieces of your insurance plan.

Deductible: The Deductible is the cost of services that will be the responsibility of the patient prior to any insurance contribution towards that cost. In recent years, deductibles have crept up, often in the $2,000-5,000 range, but sometimes over $15,000! When you have a deductible for In Network services, you will initially be asked for your typical copay (often between $20-50, sometimes as high as $150, more on that later) every visit. Later, when your insurance company has processed the claim and applied that to your deductible, the bill is forwarded on to you. I have seen these bills be north of $3,000! That can be a shock when you thought the service would be covered aside from the copay. 

Copays: Oftentimes, plans have copays associated with office visits. PT is usually considered a specialist service, so it sometimes has an even higher copay associated with it. The most typical is between $25-50, but I’ve treated patients in the past who had as high as $150! At 2x/week, that was more expensive than if they paid the clinic cash, but because the clinic has a contract with their insurance company, they are unable to charge a different rate. Also, recall the deductible: the $150 was the upfront cost of treatment, the bill will be coming later if the deductible has not been met. At 2-3 x/week, which is the most common frequency at many In Network clinics, you can expect an upfront cost of $40-100 or more per week, even if your deductible is met. 

If you’ve been In Network, you’ve likely experienced one of the following scenarios:

1. You’ve had a 1:1 appointment but it’s either shorter and rushed (30 minutes is common), with a different provider every visit regardless of availability, or both.
2. You were double, triple, or even quadruple booked and had minimal face time with your actual therapist. You spent a lot of your session being helped by an aide. The majority of PTs and staff that work in their clinics are good, kind people who are good clinicians or support staff, but are simply stretched too thin to provide top tier care. 

The Elevated Experience is 1:1 with a Physical Therapist or PT Assistant for a full hour. Sometimes, we even treat you at the same time to make sure your care stays consistent and the highest quality moving forward. The plan of care is what you need, not what your insurance company reimburses the best for or allows, and as a result, a full body approach can be taken to not only address your current areas of pain/injury but identify any areas of concern to avoid future injury.

Our cost up front is often less than what you will eventually pay at an In Network clinic to meet your deductible and may be eligible for reimbursement from your PPO plan. Even if it isn't a lower cost, it is a superior service in every way. We offer a FREE screening call to discuss your situation and needs, and guidance to help you know how to verify your benefits and submit for reimbursement from your insurance if that's something you hope to do. Give us a call today to discuss if we are the right fit for you!

Move Well,

David Frasier, PT, DPT